New model reduces waiting times for women with pelvic floor conditions

Physiotherapists at four hospitals are involved in a project to implement advanced practice roles in urogynaecology, urology and gynaecology to reduce waiting and consulting times to access specialist treatment. The project, funded through a Department of Health and Human Services grant, has been trialled at Monash Health, Sunshine Western Health, The Royal Women’s Hospital (RWH) and Barwon Health since December 2014.

In the treatment model, physiotherapists undertake initial consultations with patients using exclusion and inclusion criteria to identify those appropriate for physiotherapy management before medical specialist consultation. Monash Health, Barwon Health and Sunshine Western Health have since implemented it as an ongoing program. Dr Margaret Sherburn, FACP, Head of Physiotherapy at RWH during the trial and now Coordinator of Women’s Health programs at the University of Melbourne, says continence and women’s health is a growth area for physiotherapists.

‘The medical profession and government will be interested to receive reports on the success of this project, as they will now have a model to reduce costs in this area and improve efficiencies,’ Margaret says.

Although an advanced practice role was not implemented at RWH, the trial did improve triage processes in the urogynaecology clinics, which should potentially reduce future waiting lists, says senior physiotherapist and now Head of Physiotherapy at RWH, Donna Smith.

‘It takes a lot of courage for a woman to admit she has a problem— it’s in some ways synonymous with anxiety and depression,’ Donna says. ‘When she finally talks to her GP and actions this, then it’s important she receives care in a timely manner.’

‘We do a lot of bladder training, voiding function, defecation dynamics, a whole range of different things, as well as your classical muscle training, biofeedback and electrical stimulation,’ Robyn says.

‘The more awareness people have of that, the more they understand how an advanced practice role can fit in… in getting clients to the right care, as soon as possible.’

Adds Margaret: ‘Research evidence says women do better if they have at least three months of conservative management, ie, physiotherapy before they have surgery. This model allows that to happen easily.’

With mixed success in the trials, key learnings include ensuring adequate stakeholder engagement with other health professionals before implementation to prevent a ‘breakdown of professional or personal boundaries’, Donna says.

‘Without doctors and nurses on board, understanding and seeing the advantage of it, it can become a big challenge,’ she says.

In assessing the Barwon and Monash results, professional services firm PricewaterhouseCoopers report a 40–50 per cent reduction in time and cost per occasion of service. An assessment of Western Health is to come. When the advanced practice project was introduced at Monash Health, 727 people were on the pelvic floor clinic waiting list, Robyn says. It dropped to 609 during the 12-month project and now stands at 243.

Barwon Health’s initial waiting list had 386 women, which dropped to 328 from February to December 2015. Robyn attributes Monash Health’s success to collaboration and education with specialists.

‘We had a physiotherapist working with the urogynaecologist, taking immediate referrals,’ Robyn says. ‘So, we had that baseline of an established relationship and understanding of the importance of physiotherapy for these women. The reduction in time from referral to first appointment was a really important outcome for patients receiving timely care.’

Other outcomes include a 100 per cent patient agreement with clinical care and decision-making, and a 58 per cent improvement in meeting best practice guidelines.

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There are different models of advanced practice. The model at Monash Health starts with the physiotherapist and consultant reviewing paper referrals during triage. Using criteria, patients are identified as appropriate for advanced practice physiotherapy assessment as a first point of care. Urgent patients are referred to doctors.

Advanced practice clinical skills in assessment may include:

pelvic organ prolapse quantification scale (POP-Q)

dipstick urinalysis

referral for urodynamics

an understanding of results and ultrasound assessment of post-void residual bladder volume.

Patient and physiotherapist then discuss management options, with appointments made either with outpatient physiotherapy or an urogynaecologist. The physiotherapist then reviews patient cases with the urogynaecology consultant or fellow.

The multi-site project group developed competencies in these advanced practice skills and post-project implementation Monash Health also developed pessary assessment and review competencies. These competency and training packages will be published on the Department of Health and Human Services website later this year.

Barwon Health and Monash Health won the Best Abstract Presentation Award at this year’s APA Business and Leadership Conference.

Earlier this year, non-for-profit organisation Scope launched its first specialised physiotherapy service for rural Victorian children - GoKids Mobility Service. Dr Jennifer Fitzgerald, APAM, speaks about the dream that became reality.